Tubal ligation and vasectomy

Surgical Sterilization: Contraceptive method

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Sterilization is a permanent form of birth control that is extremely effective at preventing pregnancy. But it is difficult to reverse if you change your mind, and it does not protect against STDs. Both men and women can be sterilized. For women, a tubal ligation is performed; for men, a vasectomy is performed.

Tubal Ligation

Tubal ligation is a surgical procedure used as birth control for women. During this procedure, the fallopian tubes are tied, clamped, cut, banded or sealed closed. This prevents an egg from moving from the ovary through the fallopian tube where it could meet sperm, and it prevents sperm from traveling up the tube to meet the egg, preventing pregnancy.

Female sterilization through tubal ligation is primarily used to permanently prevent a patient from having a spontaneous pregnancy (as opposed to pregnancy via in vitro fertilization) in the future. While both hysterectomy (the removal of the uterus) or bilateral oophorectomy (the removal of both ovaries) can also accomplish this goal, these surgeries carry generally greater health risks than tubal ligation procedures

Bilateral tubal ligation may be performed postpartum using the Pomeroy, Parkland, Uchida, or Irving techniques through a small infraumbilical incision.  Interval bilateral tubal ligation is usually performed with the laparoscope using electrocautery, silastic bands, or spring clips.  Hysteroscopic transcervical microfilament placement is a newer alternative for interval tubal occlusion. 

The U.S.  Collaborative review of Sterilization (CREST) study is the largest U.S. study on female sterilization.  It reports a 10-year cumulative failure rate of 18.5 pregnancies for every 1000 procedures.  This is higher than previously thought.  Failures may occur as long as a woman is fertile, not just in the first 1-2 years following the procedure.  Failure rates were higher in young women and with specific methods (spring clips and bipolar electrocautery compared to postpartum sterilization).  However, sterilization remains the most effective method of contraception (regardless of technique) for women >34 years.  It is important to note that long-term reversible contraceptive methods (implants, DMPA, and IUDs) have annual failure rates of about 2/1000 – very close to the failure rates of sterilization.  

The advantages of sterilization include permanence, effectiveness, and lack of side effects.  The disadvantages are surgical risk (mortality 1-2/100,000), risk of regret, and risk of ectopic if pregnancy should occur. 

A bilateral tubal ligation protects against ectopic pregnancy compared to not using contraception.  However, in the few pregnancies which do occur, there is an increased risk (33% compared to 1.5% in the general population).  Regret occurs more often in young patients, in postpartum or postabortion tubals, and when patient’s life situation changes.  Tubal reversal is expensive and successful in only 43-80% of cases.  In vitro fertilization is a very successful option for young women who desire a child after tubal ligation (about 50%/IVF cycle) but is quite expensive. Therefore, a patient should be certain that she doesn’t want more children prior to having a bilateral tubal ligation. 

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Newer hysteroscopic transcervical sterilization for women offers similar effectiveness with less operative risk.  The Essure procedure involves hysteroscopic placement of microfilaments which induce a fibroblast reaction and elicit complete tubal occlusion in 3-6 months.  Benefits are high efficacy and potential for application in the clinic under local anesthesia.  Unfortunately it is not immediately effective and FDA guidelines currently require an HSG at 3 months to document tubal occlusion. Tubal reversal is not possible for those with regret, although IVF is still an option.

Tubal ligation

Vasectomy

Vasectomy is a surgical procedure for male sterilization or permanent contraception. During the procedure, the male vasa deferentia are cut and tied or sealed so as to prevent sperm from entering into the urethra and thereby prevent fertilization of a female through sexual intercourse. Vasectomies are usually performed in a physician’s office, medical clinic, or, when performed on an animal, in a veterinary clinic—hospitalization is not normally required as the procedure is not complicated, the incisions are small, and the necessary equipment routine.

There are several methods by which a surgeon might complete a vasectomy procedure, all of which occlude (i.e., “seal”) at least one side of each vas deferens. To help reduce anxiety and increase patient comfort, men who have an aversion to needles may consider a “no-needle” application of anesthesia while the “no-scalpel” or “open-ended” techniques help to accelerate recovery times and increase the chance of healthy recovery

Due to the simplicity of the surgery, a vasectomy usually takes less than thirty minutes to complete. After a short recovery at the doctor’s office (usually less than an hour), the patient is sent home to rest. Because the procedure is minimally invasive, many vasectomy patients find that they can resume their typical sexual behavior within a week, and do so with little or no discomfort.

Because the procedure is considered a permanent method of contraception and is not easily reversed, men are usually counseled and advised to consider how the long-term outcome of a vasectomy might affect them both emotionally and physically. The procedure is not often encouraged for young single childless men as their chances for biological parenthood are thereby more or less permanently reduced to almost zero, but ultimately is up to their own comfort in possibly wanting to conceive a child with a partner.

Vasectomy is safer, less expensive, and more effective than traditional postpartum or laparoscopic female sterilization.  The one year failure rate is 0.15% compared to 0.5%.  The cost is about 1/3 that of bilateral tubal ligation.  Vasectomies are performed in the office with local anesthetic.  Two semen analyses must be negative for sperm (approximately 15-20 ejaculations) after the procedure.

Vasectomy
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